Hormones and Your Health: The Smart Woman's Guide to Hormonal and Alternative Therapies for Menopause

Table of Contents

Also by Winnifred B. Cutler

Title Page

Copyright Page

Dedication

Acknowledgements

Introduction

Chapter 1 - Take Ownership of Your Health

Your Choice of Physician

Your Doctor’s Economic Dilemma

Divergent Agendas and Interests

Media Need Catchy Sound Bites

Generic Drugs Flourish

Your Power as a Health Consumer

From Age Forty Onward: The General Order of Things

Chapter 2 - Taking Hormones for Good Health: Why You Will Benefit from ...

Timing Matters

The Innate Wisdom of Your Body

Hormone Therapies Are Just Better—for Some Deficiencies

Your Longevity Clock Ticks On to Menopause

Finding the Right Way to Prescribe Hormones

How Hormones Got a Bad Name

The Panic Subsides

The Unambiguous Benefits of Hormonal Therapies

Hormone Therapies Are Not All the Same

Chapter 3 - Prescription Hormones: How to Choose Them, How to Take Them

The Essential Estrogens

The Powerful Progesterone

Traces of Testosterone

Labeling: Synthetic versus Bioidentical

Chapter 4 - Complementary and Alternative Practices: Some Good, Some Bad

What Remedies Are Women Using?

The Key Dangers of Complementary Practices

Herbal Supplements Specifically Touted for Menopausal Women

Natural Estrogens

The Foods and Nutrients We Eat: Learning from Scientific Research

Wholesome Eating Plans

Exercise: The Real Fountain of Youth

One Habit to Kick

Two Supplements to Consider

Other Complementary Practices

Conclusion

Chapter 5 - Pelvic Problems: Bleeding and Pain—Hyperplasia, Cervical Cancer, ...

Unexpected Vaginal Bleeding

Medical Evaluation of the Uterus

Hormones and Hyperplasia

Surgical Management of Unwanted Bleeding

Endometriosis: Pain in the Pelvis

Another Cause of Unexpected Bleeding

Avoid a Hysterectomy

Conclusion

Chapter 6 - Declining Pelvic Muscle Tone: Pelvic Prolapse and Urinary Incontinence

Prolapse: Fairly Common, but Not Deadly

Urinary Incontinence (UI)

What You Should Know about Surgical Devices and Therapies

Conclusion

Chapter 7 - Diagnosis Fibroids: The Top Four Treatments and Why They May or May ...

What Are Fibroid Tumors?

Why a Hysterectomy Should Be Your Last Choice

Invasive Treatments

Conclusion

Chapter 8 - Protect Your Bones—with Exercise, Posture, Vitamin D, Calcium, and Hormones

Bank on Your Bones

Hysterectomy and Bone

Bone Tests: Keep It Simple

Defining Osteoporosis

How Exercise Affects Bones

Good Posture Helps Your Bones

Get Enough Sunlight to Boost Your Bones

Bones in the Buff

Calcium: It Does Your Body Good

Increasing Bone Density: Reducing Fractures

Vitamin D and Calcium: Striking the Right Balance

How Sex Hormones Protect Bones

Which Hormone Regimens Are Best?

Osteoarthritis and Hormones

Bone-Saving Drugs

Conclusion

Chapter 9 - Keep Your Heart Strong and Your Blood Flowing through Unclogged Vessels

The Gender Difference

Hormones and Clogging Vessels

Take Action to Improve Your Cardiovascular Health

The Cardiovascular Argument for HRT

The Importance of the Delivery Route of Hormonal Therapy

Sequential Progestin: Three HRT Regimens Compared

Estrogen and Sequential Progesterone Can Be a Winning Combination

Conclusion

Chapter 10 - Protecting the Breasts: The Hidden Truth about Mammography, ...

What You Should Know

Hormones and Breast Cancer

Recent International Studies

The Protective Power of Testosterone in Hormone Therapies

A Randomized, Controlled Trial of Hormone Therapy and Breast Cancer

Weighing Your Risk

Conclusion

Chapter 11 - Hormones and the Brain: Preserving Memory, Alertness, and Optimism

Memory

Stress

Estrogen and the Central Nervous System

Conclusion

Chapter 12 - Your Changing Sexual Life and What You Can Do about It

Factor In Our Culture

Studying Sex

Getting in the Mood

Our Sexual Perceptions Count, Too

Sexual Desire

The Effect of Age and Estrogen

The Brain-Cervix Connection

Surgery and Sexuality

Hidden Sexual Problems

Seeking Help for Sexual Complaints

Hormone Therapies and Sexuality

Researched Regimens

What a High-Quality Sexual Life Requires: Knowing Yourselves Respectfully

Conclusion

A Note to the Reader

References

Index

Also by Winnifred B. Cutler

Love Cycles: The Science of Intimacy

Hysterectomy: Before and After

The Medical Management of Menopause and Premenopause: Their Endocrinologic Basis (with Celso Ramon Garcia, MD)

Menopause: A Guide for Women and the Men Who Love Them (with Celso Ramon Garcia, MD and David A. Edwards, PhD)

Menopause: A Guide for Women and Those Who Love Them, Second Edition (with Celso Ramon Garcia, MD)

Searching for Courtship: The Smart Woman’s Guide to Finding a Good Husband

Wellness in Women after 40 Years of Age: The Role of Sex Hormones and Pheromones (with Elizabeth Genovese, MD)

Copyright © 2009 by Winnifred B. Cutler, PhD. All rights reserved

Published by John Wiley & Sons, Inc., Hoboken, New Jersey

Published simultaneously in Canada

Illustrations copyright © 1986 by Athena Institute for Women’s Wellness, Inc. Tom Quay General Counsel

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax (978) 646-8600, or on the web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 748-6008, or online at http://www.wiley.com/go/permissions.

The information contained in this book is not intended to serve as a replacement for professional medical advice. Any use of the information in this book is at the reader’s discretion. The author and the publisher specifically disclaim any and all liability arising directly or indirectly from the use or application of any information contained in this book. A health care professional should be consulted regarding your specific situation.

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Library of Congress Cataloging-in-Publication Data:

Cutler, Winnifred Berg.

Hormones and your health : the smart woman’s guide to hormonal and alternative therapies for menopause / Winnifred Cutler.

p. cm.

Includes bibliographical references and index.

eISBN : 978-0-470-52553-1

1. Menopause—Hormone therapy—Popular works. 2. Menopause—Alternative treatment—Popular works. 3. Women—Health risk assessment—Popular works.

I. Title.

RG186.C9268 2009

618.1’75061—dc22

2008055869

To the research scientists who left a trail the author followed,

and to the smart women and physicians who join

this expedition.

Acknowledgments

Grateful acknowledgment is due to many friends and colleagues who have contributed to this book, and to the hundreds of cited scholars whose published studies and commentaries shaped my conclusions.

To Loretta Barrett, my literary agent, for her vision in helping me define the scope of the book and in guiding its early editorial focus, and for her extraordinary professionalism in producing this work for women and their physicians who can benefit from it.

To Stephanie Young, whose editing work on the entire text and journalist’s expertise have dramatically enhanced its readability.

To the Athena Institute for Women’s Wellness management team: Tom Quay, Esq., for his legal erudition about the FDA, Big Pharma, due process, and withstanding scrutiny, and his editorial contributions to every aspect of the book. To Glynis Gould for helping to edit for clarity and good English usage every chapter several times. To Jodie Cohen for creating the computer data management system used in tracking the 900 references and her lighter editing from a reader’s perspective.

To the professional experts in medicine and scientific research whose detailed critiques increased both clarity and accuracy and helped lead me to my independent conclusions occasionally at variance with theirs, especially two fellows of the American College of Obstetricians and Gynecologists: Drs. Millicent Zacher in the United States and Regula Burki in Switzerland. To Dr. Elizabeth Genovese, who kept feeding scientific papers to me and sharing her expertise in quality assurance and internal and occupational medicine. I thank Dr. Janet Daling of the Fred Hutchinson Cancer Center for her substantial critique of the breast chapter. Her epidemiological studies of HRT and breast cancer have spawned a significant group of trained scientists and an important body of knowledge. Dr. T. Maruo in Japan for his correspondence on uterine myoma and for sending the research papers of his extraordinary team of scientists. To Mary Lou Ballweg, one of the founders of the Endometriosis Association, who encourages important research in this difficult field.

To the wonderful Athena Institute college student interns who worked as manuscript assistants during the six years the research was under way: Maggie Parlapiano, Suzanne Smith, Leigh Bausinger, Rachel Nagourney, Lauren Fell, Amy Midgley, Kara Gillam, and Kendra Johnson.

To the participating Athena Institute staff: Cathy Peluso, Alice Sarajiandenty, Julia Liebhardt, Maria Kenny, Laura Gergel, Cindy Wilson, and Cynthia Allen.

Thanks to those women who reviewed chapter drafts, offering critiques aimed at improving intelligibility for end users, especially Lynne Avram, Melanie Wilson, Susan Kersch, and Anna Mae Charrington.

And, finally, to the excellent team of editors at John Wiley & Sons for their faith and guidance in bringing this book to press: Tom Miller, Christel Winkler, Lisa Burstiner, and Patricia Waldygo.

Introduction

YOU CAN DROP OFF YOUR CAR for routine maintenance and repair, but you shouldn’t leave the diagnosis, the cure, and the routine maintenance of your body to impersonal experts. Only at your peril do you give up control of the magnificent body in which you live and move and experience life.

I wrote this book in an attempt to combine good sense and good science. In it, I summarize current research so that women and their physicians can work together to improve the quality of health care for women. This is the mission that drives my work.

It also fulfills a promise I made thirty years ago to my late mentor and graduate-study adviser, Celso Ramon Garcia, MD, of the University of Pennsylvania. He was a renowned surgeon, a brilliant intellect, and one of the fathers of the oral contraceptive the Pill. In 1979, with a biology PhD in hand, I left the University of Pennsylvania for Stanford as a postdoctoral fellow in physiology to cofound the Stanford Menopause Study. Eventually we reported that, contrary to then current gynecological texts, the sex lives of menopausal women were not defunct. In 1983, Dr. Garcia and I wrote Menopause: A Guide for Women and the Men Who Love Them with Professor David Edwards at Emory University. This led to a medical publisher’s invitation to coauthor a textbook for physicians, The Medical Management of Menopause and Premenopause: Their Endocrinologic Basis. Four other books followed. Unfortunately, a few years later, one large study sent us back into the Middle Ages, because its data were misunderstood, misinterpreted, and misreported.

In 2002, panicky headlines announced that the Women’s Health Initiative (WHI) Study, a massive federally funded trial, was being abruptly halted because women who were taking hormones were suffering more strokes and breast cancer than those on a placebo. But the Food and Drug Administration (FDA), certain medical societies, and many physicians misunderstood the atypical population that was studied and incorrectly jumped to the conclusion that the WHI results applied to all women and all hormone therapy regimens. Doctors told their patients to stop taking hormone-replacement therapy. What a shame that was! Panic trumped good science.

In this book I have explained what good scientific analysis teaches relevant to your unique needs to help you recognize the various agendas behind the advice from media, clinicians, big drug manufacturers, disease associations, and promoters of alternative medicine. As you will see, I believe that some hormone regimens are fabulous for women but that other products (and services) serve the purveyor’s best interest rather than yours. You need to know that I have never received any research funding, tips, trips, or consulting or speaker’s fees for products or services that I pan or praise. I have no hidden agenda.

Hormones and Your Health is for both you and your doctor. It represents thirty years of careful study of published scientific research and tries to answer the big question: What’s a woman to do to improve her health, increase her longevity, avoid preventable conditions, and live life to its fullest? If you are willing to commit to learning the material in this book, you will be able to navigate this minefield to achieve your optimal health. The task is worth the effort!

1

Take Ownership of Your Health

YOU ARE IN CHARGE OF YOUR HEALTH. No one else should do it for you. No one else can feel what you feel when your energy is soaring, your sense of joy is boundless, your bones and muscles are vibrant as you stand erect and move gracefully through your days, and your immune system is strong enough to fight off the never-ending bombardment of pathogens. Don’t accept less than what is best for you. As a functioning, intelligent adult, you have many decisions to make that will affect both the quality and quantity of your remaining years. Let’s start with the first decision you make: your choice of physicians.

Your Choice of Physician

You need and deserve a relationship with a compassionate physician who respects your intelligence, your dignity, and your time. If a doctor keeps you sitting in the waiting room for an hour past your appointment, without explanation or apology, that treatment is disrespectful. Find a doctor who respects you.

Most doctors simply do not have time to read all of the scientific papers I explain in this book. As a scientist, I have studied more than three thousand peer-reviewed, published papers, and I cite nearly nine hundred here as references.¹⁷³ Your physician will appreciate the rigorous research that this book clarifies for both of you.

Your Doctor’s Economic Dilemma

Contrary to a widely held view, your doctor may not be rolling in money. Medical school is hugely expensive: $200,000 for tuition and related costs is not uncommon. Malpractice insurance for gynecologists who perform even minor surgery can easily exceed $100,000 per year. Medical insurance companies and HMOs systematically reduce payments to doctors. To cover costs, more patients must be seen, with less face time being spent with each one.

Divergent Agendas and Interests

Your physician must rely on pharmaceutical sales representatives and Big Pharma-sponsored continuing medical education courses to stay up-to-date on essential information about drugs and medical devices. The reps and the speakers do present truthful, FDA-approved data, but they have no incentive to discuss their competitors’ products. And funded speakers, as well as medical societies, are usually reluctant to pan the products of a drug company that has provided trips and money. Conflicts of interest are very serious, and they are endemic. On February 28, 2007, the Philadelphia Inquirer reported, Ex-FDA Chief Must Pay $90,000 in the Stock-Disclosure Case⁸⁶⁴—stock in drug companies that he was regulating, which he forgot to disclose. This news is not reassuring. Similar disclosures have been in the news about journal presentations as well. Editors and medical society leaders who control which research gets presented to physicians and scientists should disclose, not hide, their own, as well as their protégés’, funding sources.

Fearing malpractice attorneys, your doctor may practice defensive medicine by ordering redundant, expensive tests for you. Or sometimes doctors may stick to defensively postured practice guidelines that serve their, rather than your, best interests, in order to minimize their liability. You need to take charge of your own health and well-being; consult with the best medical people you can find and decide which recommendations to accept.⁷⁵⁴ And you need to identify the economic interests behind the recommendations that are offered to you.

Media Need Catchy Sound Bites

Have you seen articles titled Estrogen Replacement Therapy Triples Risk of Breast Cancer? This statement is more false than true and is definitely misleading. The triple actually meant an increase from 1 woman in 10,000 to 3 women! And the statistic applied only to a group of women taking a regimen of synthetic progestin every day with a horse-derived oral estrogen, a regimen I believe you should avoid. Don’t be misled by catchy headlines that are designed in part to sell newspapers.

Alternative natural therapies abound. The FDA, however, does not evaluate herbal or other alternative remedies. Do not trust advertisements for such products and services that claim to cure serious diseases with no side effects.

Generic Drugs Flourish

The FDA does regulate generic drugs and assures us that they are as reliable as brand-name drugs. But some recent published studies cast doubt on whether their quality is equal.⁴³⁴,⁷¹⁹ If you can afford brand-name drugs, you might be better off buying them.

Your Power as a Health Consumer

As a patient, did you know that competition for your business is real? Consider the inherent conflicts when you get medical advice. Your doctor can help you only within his skill set. Will he or she refer you to another physician who can offer you a less-invasive or less-costly treatment? ⁵⁴³ No law says that a doctor must do this.⁶⁹⁸

From Age Forty Onward: The General Order of Things

The chapter topics in this book follow the order of health issues that women will encounter beginning in their early forties—or sooner, if they undergo a hysterectomy before then.

1. The perimenopausal changes that women experience from age forty to forty-eight (hot flashes, night sweats, and unexpected bleeding) signal the loss or decline of progesterone, followed by erratic changes (plummets and peaks) in estrogen. These early body signals are storm warnings that your sex hormone production is winding down for its eventual sharp decline.

2. There are two kinds of remedies to consider: hormones and alternative treatments. You will learn which hormones are being marketed and which ones you should know to request or avoid, and why.

3. The following pelvic problems and their prevention and correction are addressed because they occur in the majority of women.

• Bleeding abnormalities that 80 percent of women experience in their forties drive them to doctors, who often incorrectly prescribe a hysterectomy. This actually exacerbates the hormonal problems and shortens the woman’s lifespan.

• A weakening of the pelvic floor and the consequent urinary incontinence (experienced by 30 percent of thirty-five-year-olds and 65 percent of sixty-year-olds) can often be prevented by taking appropriate hormones, beginning an exercise program, and cultivating other healthful habits.

• Prolapse problems (65 percent of women will have them by age sixty) also lead doctors to suggest surgery, whereas exercise is more often a better remedy (it’s cheaper, safer, and usually more effective than surgery).

• Fibroid tumors (80 percent of women develop them) are related to the hormonal changes that begin in the forties, but fibroids are seldom life threatening. Many doctors will prescribe a hysterectomy, but it should be avoided, if possible, because more effective treatments are now available.

4. Waiting in the wings are the following dramatic but hidden changes that occur as a woman ages:

• Bone loss begins around age forty for most women, just as their progesterone production is declining. This degenerative, crippling disease is preventable if you take action by age fifty. Otherwise, osteoporosis can affect 80 percent of women. The widely marketed bone drugs are not nearly as effective or risk free as proper hormone-replacement therapy, exercise, healthy eating, and practicing good balancing exercises to avoid slips and falls that crush fragile bones.

• Blood vessel changes begin with the transition into menopause or are caused by certain types of widely prescribed hormone therapy, as well as by a sedentary lifestyle and unhealthful eating habits. These blood vessel changes can lead to irreversible atherosclerosis. There is a lot you can do to promote healthy vessels and a vibrant circulatory system.

• The terror that women feel about breast cancer is driven by the marketplace. The actual incidence of this disease is one-eighth that of blood vessel deterioration and maybe one-fourth as serious as bone loss, but the breast people are top-notch marketers, and they prey on your fear. I hope to dissipate this media-driven fear of femininity and female hormones. Fear itself promotes hormonal changes that are bad for your health!

5. Once you make intelligent decisions regarding your hormones, your bones, your blood vessels, and living a healthy lifestyle, you’ll find it easy to follow the advice on sexual function and cognitive capacity in this book’s final chapters.

The motto we have adopted at Athena Institute for Women’s Wellness is one that you might appreciate:

When a woman refuses to be treated with disrespect and condescension, she becomes empowered to evaluate options and make intelligent choices. By doing the work of learning about her body and improving her health habits, she is in a position to assert her power. Power begets dignity. Dignity is essential to well-being.

2

Taking Hormones for Good Health: Why You Will Benefit from Hormonal-Replacement Therapy (HRT)

ACAREFULLY SELECTED PRESCRIPTION for sex hormone-replacement therapy (HRT) can be a powerful asset for your well-being if you make informed, judicious choices about what’s right for you. Your own hormones inevitably change as your fertility begins to wane in your early forties, or even earlier after pelvic surgery. Hormonal therapies (HT) become an option worth considering. But hormone prescriptions vary. They are not interchangeable. And be aware that inappropriate regimens, incorrect doses, and poor timing can create serious risks in a minority of users. HRT and HT are used interchangeably by some experts. Others confine HRT to reflect formulations that are replacing natural human hormones with chemically bioidentical substances.

Timing Matters

The inevitable decline in the ovarian secretion of estrogen and progesterone causes severe symptoms in about 25 percent of women as they age.⁵⁵⁵ Women vary. Progesterone imbalance is usually the first hidden change. Its consequence can be excessive bleeding. Estrogen changes usually occur next. For some women, an abruptly plummeting estrogen level occurs in the mid-forties, five to seven years before the average age of menopause. For others, the decline is gradual, or there may be huge spurts and troughs.¹⁷⁴ These are signals. They tell you about your life and your hormone status.

If you have a regular sex partner, you are less likely to experience abrupt roller-coaster-like changes in estrogen. But if you suddenly end a sexual relationship, your estrogen levels are likely to suddenly drop.¹⁶⁹ If you begin a judicious prescription of hormones when the deficiency signals first start, you can eliminate symptoms within days. Starting early makes a big difference in preserving the health of your blood vessels, too.¹⁴⁵

Symptoms of Declining Estrogen and Progesterone Levels

• Hot flashes

• Sweating/night sweats

• Mood swings

• Insomnia

• Vaginal dryness or atrophy

• Painful or uncomfortable intercourse

• Abnormal bleeding

The Innate Wisdom of Your Body

These symptoms of hot flashes, vaginal dryness, and sleep disturbances provide valuable signals. Uncomfortable intercourse due to vaginal dryness isn’t a wonderful experience, but it’s telling you to do something. Like an early warning signal of an impending hurricane, these symptoms are calling you to take notice so that you can avoid the storm. Listen to the signals your body sends, and you can take preventive actions that will enrich the second half of your life.

Of course, you can grit your teeth, be uncomfortable, and accept the inevitability of growing older and eventually disabled. But keep in mind that the majority of postmenopausal women who do not use hormonal-replacement therapy will not merely experience unpleasant symptoms; they will risk diseases brought about by loss of bone, loss of blood vessel elasticity, and decreased protection from cardiovascular disease.¹²¹,⁵⁵⁵ You may not need hormones. You may have a body that produces all you need. Or you may not be a good candidate due to your family history. Ask your clinician to discuss options related to your own personal health history. But read this book first!

Hormone Therapies Are Just Better—for Some Deficiencies

Hormone-replacement therapies are obviously not the only route to good health. There are alternative paths to maximize your health that I describe throughout the book, such as exercise, weight loss, and quitting smoking. But for hot flashes, bone loss, atherosclerotic change, and sleep disturbances, correct hormone therapies appear to offer the most efficient, effective remedies. They have consistently outperformed alternative remedies, including placebos, tranquilizers, sedatives, herbal remedies, and other drugs.¹⁶⁸,¹⁷¹,¹⁷⁵,⁷⁵⁹ Unlike other prescriptions from your doctor, they can be used to prevent disease. (Of course, exercise and other healthy habits are still important, with or without hormone therapy.)

Long-term hormone therapy is associated with lower death rates in older women.⁵⁸² I believe that a powerful argument can be made against the current recommendation that hormones are all right but in as low a dose as possible for as short a time as possible.⁵⁸² The data published by hundreds of outstanding biomedical scholars convince me that carefully chosen long-term therapy may extend the length and the quality of your life leading up to menopause and for many years thereafter.

Your Longevity Clock Ticks On to Menopause

Menopausal describes the part of your life that follows your last menstrual cycle—not only the cessation of menses, but also the change in ovarian secretion of hormones that drive the menstrul cycle: estrogen and progesterone most notably. Worldwide, this occurs at the average age of fifty. The later the onset of menopause, the longer a woman is likely to live.⁵⁷⁹ Unfortunately, ten years into the course of untreated menopause, atrophy (degeneration) of the urogenital tissues affects up to 47 percent of women.⁷³¹ Later effects of postmenopausal hormonal deficiencies include declining strength in the bones and the cardiovascular system.

Postmenopausal hormonal deficiencies can lead to:

• Decline in bone quality

• Diminished cardiovascular health

• Urogenital atrophy

• Wrinkled skin

• Blood vessel thickening and atherosclerosis

• Cognitive decline

• Increase in fat, decrease in muscle

Having a hysterectomy speeds up your aging clock. The surgical removal of the uterus accelerates your entry into menopause.⁵⁷⁹ Having an ovariectomy speeds up the aging process even more,⁵⁹³ because your estrogen-progesterone factories, your ovaries, have been removed.

After a hysterectomy, women have an even higher risk of developing hormone-related deficits than intact aging women have.²¹⁶ It’s best to keep all of your healthy internal organs as you age.⁵⁹³ If the uterus was removed but the ovaries were retained, the normal menopause-related decline in the ovarian production of estrogen and progesterone hormones is likely to occur much earlier than the intact woman experiences. Unfortunately, this leads to serious consequences: even lower bone density, increased cardiovascular disease (CVD) risk, and more severe estrogen-deficiency symptoms.²¹⁶,²³⁶ How severe? It depends on how early in life the surgery was performed.

For women who were hysterectomized at age 42, menopause seemed to follow within 2 years, instead of in 8 (at age 50). For those hysterectomized at age 44, ovarian failure occurred with in one year. And for 45-year-olds, it was immediate,⁷⁰⁵ a 5-year acceleration of their aging.

This is not trivial. If you have had a hysterectomy and/or an ovariectomy, you can take effective action—the earlier, the better.

By 2005, a large and well-done analysis had proved that at no age was it ever beneficial to remove healthy ovaries during a hysterectomy. Avoiding castration (ovariectomy) until age 65 clearly benefits the long-term survival of women who undergo a hysterectomy for a benign disease. The incidence of developing ovarian cancer after a hysterectomy is 40 percent lower than in the general population,⁵⁹³ so there is no logical reason to remove healthy ovaries. But the most sensitive risk was coronary heart disease; having an ovariectomy increases the risk of cardiovascular disease, the main cause of death for women.⁵⁹³ The younger a woman is when she has an ovariectomy, the greater the chances for harm.

Unfortunately, despite the facts, in 2005, data from the Centers for Disease Control (CDC) showed that 78 percent of women in the United States who underwent a hysterectomy between the ages of 45 and 64 were also castrated. A survey of Taiwan gynecologists found that the same practice was common there.¹²⁸ What this means to me is that women need to recognize their right to refuse suggested surgery.³⁹⁶,⁴²⁸ You should refuse to accept castration unless cancer is looming.¹⁷⁰,⁵⁹²

By 1989, medical societies routinely showed their member physicians the many benefits of HRT. Hundreds of studies had been published to prove that women could be spared osteoporosis, vaginal atrophy, and many other age-related diseases that were apparently the result of declining levels of sex hormones. But it took some time for the medical establishment to get on board.

Finding the Right Way to Prescribe Hormones

From the get-go, medical science didn’t get it quite right. First, estrogen, unbalanced (or unnopposed) by progesterone, was widely prescribed. ¹⁶⁷,¹⁷¹ Only after researchers discovered that women risked developing endometrial hyperplasia when they took unopposed estrogen (which increased the rate of uterine cancer) did it become apparent that Mother Nature had it right in generating the sequential pattern of secretion of ovarian sex hormones in fertile women. Women needed progesterone, ten to fourteen days a month when they took estrogen every day. Some brilliant work on optimizing prescriptions for hormonal balancing for uterine health by gynecologist Dr. R. Don Gambrell has spanned more than thirty years. Until his death in 2007, he continued to publish his studies calling for other physicians to recognize which regimens women need to optimize their hormonal therapy.²⁵⁷,²⁵⁸ I call it nature’s design.

Dr. Gambrell showed that the closer a prescriber came to providing the progesterone the way Mother Nature designed in a woman’s fertile years, the better off the woman’s uterus was.¹⁷⁴,²⁵⁸ She needed progesterone for about half of the month, when she took estrogen every day. As you will see in later chapters, these sequential regimens also lower the risk of breast cancer and build better bones, better mental function, and a healthier cardiovascular system.

Why aren’t women routinely offered this choice? Unfortunately, two large randomized, controlled trials (RCTs) tested a regimen that did not mimic nature, and the outcomes were not so good. I believe that the incorrect interpretation and the publicized results triggered a very serious health setback for women.

How Hormones Got a Bad Name

Two very large studies were conducted with the aim of finding out how hormones would benefit women. It is worth noting that these studies used a specific regimen, but their results were generalized to give all hormones a bad name.

What: The first study, called HERS (the Heart and Estrogen/ Progestin Replacement Study), was a randomized, blind, placebo-controlled trial of the effect of Prempro (a pill combining a horse-derived estrogen and a synthetic progestin) on coronary heart disease (CHD) risk.

Who: 2,763 postmenopausal women with documented CHD.

Result: The regimen did not improve things.²⁸⁶ Overall, Prempro did not help lessen future CHD problems in women who already had them.

What: The second study of this same regimen was called the Women’s Health Initiative (WHI).

Who: 161,809 healthy postmenopausal women.⁶⁵⁶

Result: It, too, did not produce positive results in the early analyses of the extensive data.⁸⁵⁶ The WHI results, to the shock of many, led to a worldwide HRT panic. Here is how it started.

The Enormous WHI Study Unfolds

Between 1993 and 1998, the WHI enrolled 161,809 postmenopausal women between 50 and 79 years old at 40 clinical centers in the United States in a set of clinical trials of postmenopausal hormone use. This was a government-sponsored study, in which Wyeth agreed to supply its HRT drugs, Premarin and Prempro. The FDA approved Prempro in 1993. The goal as stated was a noble one: